Lifetime Eye Care - Online Forms for New Patients

New patients at Lifetime Eye Care are asked to fill out patient forms prior to their appointment. Please fill out all information below as completely as possible. Be sure to click the "Submit" button at the bottom when finished to securely submit the forms.

Do you use tobacco, alcohol or illicit drugs?
No, I do not
Yes (Please describe below)

Do you have any sexually transmitted diseases?
No, I do not
Yes (Please describe below)

Who is your current primary care doctor?

MedicationsPlease list all medications, vitamins and supplements that you currently use:

Current medications:

No current medications

AllergiesPlease list all allergies to medications and environment:

Allergies:

No known drug allergies

Health History

Past Ocular HistoryPlease describe if you have ever had any of the following:

Eye Diseases:

Eye Injuries:

Eye Surgeries:

Other Ocular Issues:

No history of ocular health issues

Past Health HistoryPlease list all past major health issues:

Past major health issues:

No past major health issues

Please check if you have ever had problems with any of these systems:(If you check a box, please be sure you have described those issues above in either the "current health issues" or "past major health issues" boxes)